November 16, 2012

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From the ‘Interpretation of the Jīn Gùi Yào Lüè’ by Sòng Jiàn-Píng (2009)

I am currently in the process of translating the second volume of the Jīn Guì Fāng Gē Kuò (金贵方歌括) by Chén Xiū-Yuán. I have been so immersed in it lately, that I feel I’ve been neglecting this site, and figured I should work on something to put up. Because of the intense amount of work and dedication this book requires, I figured it would make more sense to translate something I’ve been using as reference, helping myself and others elucidate the deeper meaning behind the formulas discussed in the text. The following is the small section on Xìe Xīn Tāng, for which I recently worked on. I’ve had a bit of a hard time with the line “heart qi insufficiency” (心气不足), as I’ve read several commentaries, including the Qiān Jīn Fāng, which state that this is a typo, and the actual line should read, 心气不定 (heart qi instability/unsettled). Neither one of these still make immediate sense to me, but I am getting closer to understanding what it means and it’s pathological/physiological implications. Since I am still processing and working with this line, I’ll share my thoughts on a later date. I’d love to get other perspectives in the comments section.

Use 3 shēng of water for the three ingredients above, boil until reduced to one shēng, and take in one single dose.

[Comparisons] Heart qì vacuity: In the Qiān Jīn Fāng it is written as heart qì instability/unsettled) (心气不定)

[Presentation] A treatment for patterns of blood ejection and spontaneous external bleeding due to exuberant heat.

[Explanation] Both blood ejection and spontaneous external bleeding are categorized as exuberant heat patterns. The heart stores the shén, and governs the blood vessels. If heart fire is exuberant, it will cause frenetic movement of the blood, which results in blood ejection and spontaneous external bleeding. If the spirit is harassed there will be vexation and disquietude. Xiè Xīn Tāng is the treatment of choice, which clears heat and discharges fire. Within the formula, Huáng Lián and Huáng Qín clear heat, downbear fire, and discharge heat from the heart channel, so heart blood can quiet down on it’s own. Dà Huáng is bitter, cold, downbearing and discharging. It causes the descent of fire qi so blood can be calmed and stop moving frenetically. When these three medicinals are combined, they directly break heat, downbear fire, and stop bleeding.

[Commentary] Xiè Xīn Tāng and Bǎi Yè Tāng both treat blood ejection, however, Bǎi Yè Tāng mainly treats blood ejection due to central qì vacuity cold. Typical signs seen with this presentation are a somber white facial complexion, lassitude of spirit and fatigue, pale tongue body with a white coating, and a vacuous weak pulse. Xiè Xīn Tāng treats blood ejection due to exuberant heat, which is typically accompanied with heart vexation and disquietude, a red complexion, red tongue body, vexation thirst, constipation, a rapid pulse, etc. The two prescriptions above introduce us to two major methods and treatment principles for the treatment of blood ejection. One to warm yáng and restore qì, and one to discharge fire and clear heat in order to stop bleeding. In regards to Xìe Xīn Tāngs’ treatment of blood heat with frenetic movement, bleeding can manifest in several different ways including, vomiting of blood (hematemesis), external bleeding, blood in the urine (hematuria), blood in the stools (hemafecia), etc. which can all be treated quite effectively.

This is a commonly used formula for treating exuberant heat in the three burners, and is used clinically for the congestion of pathogenic-toxic fire and heat causing disorders in either the upper or lower burners, or the exterior or interior. Examples being, the upward harassment of toxic heat causing a red complexion and tongue, ulcerations of the mouth and tongue, tooth swelling and pain, vexation heat, and oppression in the chest, or toxic heat manifesting on the exterior with skin damage due to swollen and toxic sores.

[Case Example] A sixty-year-old female patient presented on April 20, 1994. She has a history of a duodenal ulcer for many years, and has recently been quite fatigued, with unbearable epigastric pain. This morning after eating breakfast, she immediately felt nauseous and had a desire to vomit. Soon after she vomited approximately 300ml of fresh blood, which contained stasis clots but no food from her digestive tract. She has continued to feel nauseous and has been vomiting blood quite frequently up until the time of her consultation. Her tongue was red, with a thin yellow coating, and she had a wiry-slippery-rapid pulse. The diagnosis was blood ejection. The pattern belonged to heat accumulation in the stomach causing frenetic movement of the blood. Treatment involved clearing the stomach, discharging heat, transforming stasis, and stopping bleeding.

Formula:

Dà Huáng 30gHuáng Qín 9gHuáng Lián 9gDài Zhě Shí 30g

The medicinals above were to be decocted (and drunk) quickly

After taking the formula, the vomiting of blood stopped, and the epigastric pain decreased. She was continued on two more packages of the formula to clear the remaining pathogens.

November 3, 2012

The following is an article I translated a couple years ago for a mainland Chinese medical journal, I just found while digging through my hard drive. While I (luckily) don't treat lots of liver cancer, there's still some juicy content in the article, and some great classical reference. Enjoy!

Reflections on the patterns and treatment of Liver cancer

Dr. Su San-Leng

Translated
by Eran Even

Summary:

In regards to the analysis and grouping of liver cancer signs and
symptoms, we attach great importance to spleen deficiency patterns according to
the manifestation and to the developmental process of the patients’ individual
physical factors. While the basic overall objective of treatment is in the
regulation of spleen deficiency following a holistic ideology, we must also
take into account the various disease mechanisms and simultaneous accompanying
symptoms. By adhering to these factors and to the spirit of Chinese medical
pattern differentiation we are able to achieve positive results and outcomes.

Liver cancer is a very harmful condition, which is generally difficult
to treat.The prognosis for most cases
is quite poor [1] [2], usually requiring more diverse treatments.There are several pieces of literature in
existence which discuss the treatment of liver cancer, with discussions about
disease aetiology and pathology, yet most are focused in the wrong
direction.From the perspective of the
symptoms at the onset of the condition, in reality particular importance should
be focused on the pattern of spleen deficiency [3]. In conforming to the
science and study of organ manifestations, and treatments according to pattern
identification, we are able to treat the whole disease and obtain relatively
high clinical effectiveness [4].

However, there is certainly no doubt that liver cancer is a growing
concern amongst cancers.The intent of
this article is to simply illustrate the usage of the theory of treatments
based on pattern identification according to the theories of organ physiology
and pathology as the starting point, so as to draft proper and effective
treatment guidelines.With that being
said, in regards to treatment according to pattern identification, [liver
cancer] does not fall within the theory of organ manifestations, but instead we
should expound on the idea of the [spleen organ] being the core of this
clinical reality.

Examining the past:

(1)Disease mechanism and disease location:

From our document
analysis, we can see the commonly seen mechanisms involved in liver cancer are;
qi stagnation, blood stasis, congealing of phlegm, damp turbidity, toxic heat,
and deficiency damage. [5]. Although these patterns can offer an explanation as
to the progression and state of the patients’ condition, they are all however,
established and known to be based on the premise of liver cancer and are simply
used as a method of classification.In
reality, according to the initial clinical manifestation of the patient, they
are almost always based on the organ manifestation signs and symptoms of the
spleen and stomach, even to the point where, prior to the emerging of any concrete
patterns, we see various symptoms of the digestive system.Therefore, if we eliminate preconceived
thoughts and ideas, we are able to see that the disease mechanism and location
of liver cancer is in fact related to the spleen and stomach, and by this we
would be able to determine our treatment [6].Even within the developmental process of the late stages of the disease,
the signs and symptoms of the spleen and stomach are still inevitably
linked.Moreover, with a spleen
deficiency pattern, there can be simultaneous patterns such as, blood stasis,
qi stagnation, congealed phlegm, damp turbidity, toxic heat, etc. In other
words, the presence of cancer (in liver cancer) is always anatomically found in
the liver, however, the nature and occurrence of the condition is found in the
spleen according to the study of traditional Chinese medical organ
manifestations.

(2) Treatment Methods:

According to
traditional methods, most treatments involve some element of clearing heat,
resolving toxicity, invigorating blood, transforming stasis, softening
hardness, scattering binds, attacking toxins with toxins, etc, in order to
disperse and eliminate tumors [7], but in reality the results are usually
unsatisfactory.

The clearing heat and
resolving toxicity method is utilized in cancer therapy when the cause of the
cancer is heat or fire, so therefore, the treatment principle is to eliminate
and drive out pathogenic heat. However, treatment efficacy must be
assessed.It is quite common in folk
medicine to use secret recipes to treat liver cancer consisting of bitter cold
medicinals which if used for extended periods of time can damage stomach qi,
creating digestive dysfunctions and invariably decreasing immunity.

The method of
invigorating blood and transforming stasis is considered in cases of liver
tumors accompanied by cirrhosis [8] [9] [10].It is of common belief that a
definite relationship between liver cirrhosis and blood stasis exists
[11].Due to this reason, blood
invigorating medicinals are commonly used as part of a treatment plan to transform
stasis and eliminate tumors.However
simply using blood invigorating, stasis transforming medicinals in order to
disperse tumors bears very little significance, and in addition there exist
varying levels of controversy surrounding these medicinals.

The method of
softening hardness and scattering binds is also commonly used, based on the
belief that tumors are simply congealed phlegm nodules, and so therefore
medicinals are used to transform phlegm and soften hardness.However, these types of medicinals are more
suitable for certain types of abnormal glandular dysfunctions (resembling tumors),
as it is not easy to disperse hyperplastic growths or solid tumors.

It is believed that
cancer is caused by the amassment of toxic pathogenic factors of a stubborn
nature, and therefore another method used is the administration of toxins to
treat toxins. Using general herbs to achieve this function is quite difficult,
so we must therefore use toxic medicinals in order to conquer these toxins.When using these types of medicinals we must
take two issues into consideration.The
first is that many of these toxic substances are harmful to the organisms’
cells and tissues, so it is imperative that we find strong and distinctive
medicinals specific to cancer cells, otherwise we run the risk of damaging the
right qi.The second issue is that we
must be certain that the dosage administered is adequate in order to be
effective, but must question whether or not there is the possibility of damage
to the body due to accumulation (of the toxic medicinal) after reaching the desired
dose.

Looking to the future

(1) The importance of strengthening the spleen

In the early stages
of liver cancer, symptoms are generally not perceived, and once these symptoms
develop they are usually associated with the centre (spleen and stomach
organs).In the later stages of the
condition, the commonly seen symptoms
include epigastric fullness and focal distention, torpid intake, nausea,
vomiting, abnormal bowel movements, weight loss, fatigue, swelling in the upper
right abdomen, pain, splenomegaly, heat effusion, ascites, jaundice, etc.Nearly all of these symptoms are related to a
spleen deficiency pattern.Li Dong-Yuan
of the earth supplementation school declared:

“In cold deficiency and weakness of the spleen and stomach, there is
inability to transport and transform the essence of food and grain, which will
gather and give rise to distention and fullness.If there is an abundance of dampness,
distention and fullness will also be present with non transformed food.In spleen diseases there will be fatigue and
somnolence, loss of use of the limbs, and sloppy diarrhea.If food damage affects the Tai-Yin or Jue-Yin
(channels), there may be vomiting, or focal distention and fullness, and
perhaps even dysentery or intestinal aggregation”.

Essentially a pattern
of spleen deficiency losing the ability to transport and transform will give
rise to the aforementioned symptoms.

According to his
famous treatise, Li (Dong-Yuan’s) discussion of swellings and lumps in the
abdominal cavity is considerably similar to the description of liver
cancer.

“When the spleen is diseased, there should be stirring qi around the
umbilicus, which is firm and painful on palpation.This stirring qi is solid and fixed, hard as
if an accumulation, with vague pain or, in the extreme, even great pain.Presence of this stirring qi leads to the
disease of spleen deficiency”.

In the Classic of Difficulties (Nan Jing) it
is said;

“Accumulations in the spleen are
named focal distention.They are present
in the epigastrium; the abdomen is large resembling an inverted bowl, and the
condition endures without recovery. The four limbs are unable to receive,
jaundice develops, and foods and drinks fail to build the skin and flesh”.

It is written in the Comprehensive Recording
of Divine Assistance from the Zhenghe Era (Sheng Ji Zong Lu):

“Accumulated
qi in the abdomen failing to recover over an extended period, which is firm
when pressed, and immobile, is called a concretion. This is caused by cold and dampness, and/or
unseasonal foods and drinks causing spleen deficiency weakness. If foods and
drinks are not reduced, (the abdomen) will feel firm like a bowl when pressed
and the condition will seem endless. This will cause the body to become thin
and the abdomen large. Death will most certainly ensue, if this is not
eliminated”.

Regarding abdominal
water (ascites), our predecessors also believed that the cause was a spleen
earth deficiency.In the 4th
century text, ‘Emergency Formulas to Keep Up One’s Sleeve’ it is written:

“Water diseases are the result of deficiency
and damage following a major disease such as the aftermath of diarrhea or
dysentery.Fluids are unable to be
dispersed, the triple burner is diseased and urination is inhibited, gradually
producing amassment and finally spreading throughout all the channels and
collaterals”.

The fever associated
with liver cancer can be due to various factors, such as the general
feverishness associated with cancer, fever due to an infection, or the result
of a deficiency of the body, which are similar to Li Dong-Yuan’s description of
restrained and obstructed spleen yang.

“Heat in the four limbs, heat of the muscles,
sinew impediment heat, heat in the bone marrow, drowsiness, and heat in the
hands which feel like being burnt with fire.In most cases, this is caused by blood deficiency.Or it may be caused by restrained and
obstructed yang qi within spleen earth due to stomach deficiency and eating too
many chilled foods.This will result in
the effusion of depressed fire”.

Hua Tuo’s ‘Central
Treasury Classic’ says:

“In diseases of
the spleen, blood and qi will be unsettled.With this unsettling, there will be unceasing alternation of cold and
heat, which resembles malaria”.

Currently, the
formula Artemisia Yinchenhao Decoction (Yin
Chen Hao Tang) is used to treat jaundice associated with liver cancer, as
most physicians ascribe this to damp heat in the liver and gall bladder.In reality, this goes against (Zhang)
Zhong-Jing’s original intention.Zhong-Jing said:

“In Yang
brightness disease there is heat effusion and sweating.This is (due to) straying heat which is
unable to cause yellowing.If there is
only sweating from the head, and not from the body, stopping at the neck, along
with inhibited urination and thirst with intake of fluids, this indicates
stasis heat in the interior which will cause yellowing and therefore, Yin Chen
Hao Tang governs” [12].

This illustrates that
in the treatment of jaundice, the use of Yin Chen Hao Tang in reality treats
diseases of the spleen and stomach earth and not of liver and gallbladder wood.

It can be seen from a
great deal of the quotes mentioned above, and although they cannot cover the
whole story, a pattern of spleen deficiency is a solid explanation of the
majority of cases seen with this condition.According to this explanation following the principles of strengthening
the spleen is often the correct strategy to use.

(2) Whole treatment
supplementation

Holistic ideology is
one of the characteristics of Traditional Chinese medicine [13].Although liver cancer is a liver disease, it
is not seen as completely independent from the other organs.Although the treatment of malignant tumors is
difficult, by understanding the basic elements of the condition such as the
bodies’ yin and yang, cold and heat, deficiency and excess factors we see how
these imbalances can create specific conditions.Therefore, by looking at the manifestations of
the various viscera and bowels and treating according to pattern
identification, we are able to devise a treatment strategy, harmonize the body
and bring about equilibrium to the whole system.This is the same basic strategy that is
applied to the clinical treatment of tumors.

Due to the refractory
nature of this condition, we must employ other treatment methods, and this is
the part that needs to be further explored and investigated in depth.However, considering the holistic ideology
present in Chinese medicine, we must adapt a comprehensive treatment rationale
which conforms to this ideology.Under
the premise of spleen deficiency, every patient will have individual physical
characteristics, and the disease may develop in a different matter with various
outcomes.There may be accompanying patterns such as qi
stagnation, blood stasis, congealing of phlegm, damp turbidity, toxic heat, and
insufficiency of yin fluids.In the
later stages these fluids may be completely damaged similar to a pattern of
spleen and kidney dual deficiency.When
treating, we must not overlook harmonization, and from experience we know that
treating the whole is of utmost importance.

Conclusion:

According to this paper and to various
clinical reports, we see that there are numerous methods used to treat liver
cancer.However, many of these treatment
effects are rather undesirable.Paying
particular attention to the onset, location and mechanism of the condition we
find that although the symptoms are namely in the liver according to anatomical
study, the clinical manifestations and symptoms are found in the spleen.With regards to the traditional Chinese
medical theory of treatment based on pattern identification, in reality it is
the spleen that should be the main focus, and because the condition is usually
in a chronic state, one must attach great importance to treating the
deficiency.With that being said, the
core of treatment should be on spleen deficiency and addressed throughout the
entire course of therapy, remaining mindful of any simultaneous patterns the
patient may be presenting with.By
adhering to this comprehensive treatment strategy, we may be able to acquire
excellent treatment outcomes.